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HIV and AIDS HIV and AIDS Treatment

Less is More: Once-Daily HIV Therapy

For many people, it's hard to remember to take a pill every day. For people being treated for HIV, however, the prospect of taking medication only once a day seems almost too good to be true.

HIV regimens are often highly choreographed, requiring that people take many different pills at different times of the day. And missing even one dose can compromise the effectiveness of therapy. So not only would a less complicated medication regimen make life easier, it could be lifesaving.

Thanks to new research, HIV regimens have become simpler in recent years, and now some patients are candidates for once-a-day HIV therapy. Below, Dr. Brian A. Boyle, an associate professor at Cornell University Medical College in New York City, discusses the shift from complex regimens to once-daily therapy.

Why was it important to develop once-a-day dosing?
It is very difficult for patients to take medications on a religious basis like they have to with HIV therapy. The regimens doctors used to give patients could be extraordinarily complicated. For example, one pill needs to be taken on an empty stomach, but it can’t be taken with another pill that also needs to be taken on an empty stomach, because the two would interact with each other. And then there are other pills that have to be taken separately on a full stomach.

So, for some of these regimens, patients needed a computer algorithm to keep track of when they were supposed to take their medications and how they were supposed to take them. And doing this every single day of your life is difficult.

Why weren't the medications originally designed as once-a-day drugs?
Initially some of the drugs achieved very favorable treatment levels, which allowed them to be dosed once a day. Other drugs couldn't be given once a day because they wouldn't be able to achieve adequate levels throughout the day. But additional research has found that this can be accomplished by improving the way the drug is put together. “Additional research into the treatment levels achieved by the drug in important areas of the body have also led to our being able to use some of these drugs as once-a-day drugs,” says Boyle.

What drugs are available in the once-daily formulation?
All of the main classes of antiretroviral medications have drugs that have been approved for once-a-day treatment. The first drug that was approved for once-a-day, Sustiva, is a non-nucleoside. Later, drugs in the nucleoside analog class were approved and now there are medicines in the protease inhibitor class that are taken once-a-day. There are also a number of drugs that are in development or being researched as an option for once-a-day treatment.

Is everyone a candidate for once-daily regimens?
The number of patients who are candidates for this therapy is limited to those who are new to therapy and patients who have the drugs that can be given once a day as therapeutic options. If the patient has already developed some resistance to drugs, or they've already taken a number of other drugs, the once-a-day option may not be available to them.

“But I think the once-a-day approach to therapy is certainly gaining steam, and I expect to see many more patients on once-a-day therapy over the coming years,” says Boyle.

What side effects are associated with regimens using once-daily formulations?
With once-a-day regimens, the side effects that people encounter depend heavily upon the drugs that are being used. Doctors generally try to keep the total number of pills per day as low as possible to limit the side effects. With some regimens, for example, people will experience nausea, dizziness, decreased concentration, sleep disturbances, or, even, difficulty staying awake. Other side effects may include liver problems as well as rash, which can be severe.

How much of an impact are the once-a-day medications having on HIV treatment?
The impact upon the treatment of HIV-infected patients currently is limited. As time goes on and there are more and more drugs that can be given once a day, doctors are going to find more and more patients on those therapies.

Physicians will mix and match drugs in different ways to put together a regimen for patients. If you can decrease the number of pills that someone needs to take per day and decrease the side effects, patients are likely to take the medications more reliably, and that's what has to be done.